Assessment of the practicability of implementing the EULAR recommendations for the role of nurses in the management of chronic inflammatory arthritis in China

Introduction

The role of nurses is defined as being the independent practitioners educated and trained to provide health promotion and maintenance through diagnosis and treatment of acute and chronic conditions. With the emergence of new treatment regimens and social development, nurses are now playing advanced and extended roles. ¹ A study performed by the School of Nursing at the Johns Hopkins University showed that the interventions undertaken by nurses could improve the treatment outcomes and reduce the incidence of disease complications. ²

In rheumatology, registered nurses often act as the link between the patients and other members of a multidisciplinary team. ³ In 2011, the European League Against Rheumatism (EULAR) developed a set of recommendations for the role of nurses in the management of chronic inflammatory arthritis (CIA) using a combination of evidence-based and expert consensus approaches, aiming to identify appropriate research and educational agendas. According to the EULAR recommendations, rheumatology nurses should undertake self-management support, patient education and counseling, recommendation and prescription of drugs, referral to other health professionals, manning telephone advice lines and monitoring disease modification, and biological treatments for CIA patients. ³ Nevertheless, CIA management in rheumatology is in need of development into an internationally recognized nursing specialty.

CIA represents a leading cause of disability worldwide, ⁴ which results in unfavorable prognosis, high disability rate, and substantial socioeconomic burden. CIA places severe limits on the daily activity and quality of life for over 100 million people in China. The education provided by health professionals is crucial for health improvement of the patients with chronic diseases such as CIA, since they are incurable. Recently, China has proposed new requirements for chronic disease management, specifically emphasizing patient education and rehabilitation services, foreshadowing a public health storm will send ripples throughout the society.

The aim of this study is to assess the practicability of implementing the EULAR recommendations in China by evaluating its level of agreement and perceived feasibility among nurses. We hope our study will guide future education and help to develop professional training systems for CIA management among nurses and eventually promote implementation of the EULAR recommendations in China.

Methods

A cross-sectional survey was conducted in China. The study population comprised registered Chinese clinical nurses in rheumatology and immunology departments based on convenience sampling (a non-probabilistic sampling method in which respondents are randomly selected by the investigators at a particular time and location in a particular community to fit the research topic), and therefore the calculation and justification of the sample size before the study were not required. The 10 EULAR recommendations were translated from English to Chinese by a professional translator, and the accuracy was confirmed by rheumatologists. ³ Individual distribution method was used to send questionnaire links. Head nurses in each hospital were provided with a link to a questionnaire as well as instructions on completing the questionnaire. Registered nurses were informed of the aim of the survey and were provided with instructions on completing the questionnaire, Voluntary completion of survey.

Research tools

We evaluated the following parameters: age, highest education level, professional ranks and titles, years of work experience as nurses in the field of rheumatology, professional training experiences, and the level and location of hospitals. The EULAR recommendations for the role of nurses in the management of CIA are listed in Table 1.

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Table 1.

EULAR recommendations for the role of nurses in the management of CIA.

No.	Recommendations
1	Patients should have access to a nurse for education to improve knowledge of CIA and its management throughout the course of their disease
2	Patients should have access to nurse consultations in order to experience improved communication, continuity, and satisfaction with care
3	Patients should have access to nurse-led telephone services to enhance continuity of care and to provide ongoing support
4	Nurses should participate in comprehensive disease management to control disease activity, to reduce symptoms, and to improve patient-preferred outcomes
5	Nurses should identify, assess, and address psycho-social issues to minimize the chance of patients’ anxiety and depression
6	Nurses should promote self-management skills in order that patients might achieve a greater sense of control, self-efficacy, and empowerment
7	Nurses should provide care that is based on protocols and guidelines according to national and local contexts
8	Nurses should have access to and undertake continuous education in order to improve and maintain knowledge and skills
9	Nurses should be encouraged to undertake extended roles after specialized training and according to national regulations
10	Nurses should carry out interventions and monitoring as part of comprehensive disease management in order to achieve cost savings

EULAR: European League Against Rheumatism; CIA: chronic inflammatory arthritis.

The level of agreement and the perceived feasibility of the recommendations were assessed by a visual analogue scale (VAS 0 = total disagreement/completely infeasible to VAS 10 = complete agreement/completely feasible). The subjects were required to select the reasons why they disagree or consider the recommendations infeasible.

Results

In total, 485 subjects were included, and 438 valid questionnaires were retrieved (valid recovery rate = 90.3%). The subjects were from 48 first-class hospitals (comprehensive hospitals with more than 501 beds, which can provide high-level specialized medical and health services and conduct higher education and scientific research tasks to several regions) nationwide with an average age of 31.65 (±6.65) years. The average duration of working experience was 6.41 (±5.438) years. 71% of the subjects had an undergraduate diploma, 2.5% with a master’s degree, and 0.2% with a doctoral degree. 48.6% of the subjects had the professional title of senior nurse.

Analysis of the level of agreement with the EULAR recommendations among nurses

The proportions of levels of agreement with the recommendations are illustrated in Figure 1. For each recommendation, at least 80% of the subjects were in either complete or partial agreement (VAS 5–10).

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Figure 1.

Levels of agreement with the EULAR recommendations among rheumatology nurses in China.

Analysis of the perceived feasibility of the EULAR recommendations among nurses

With regards to the feasibility, more than 80% of the subjects considered the recommendations either fully or partially feasible (VAS 5–10; Figure 2).

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Figure 2.

Feasibility analysis of the EULAR recommendations in China.

Next, we assessed the factors that caused the subjects to disapprove or partially disapprove the recommendations. Our results showed that factors that contributed to total or partial disapproval of the recommendations included busy clinical nursing (39.98%), the lack of professional knowledge and nursing skills (25.7%), and the patients’ non-acceptance of the extended role of nurses (17.35%) (shown in Figure 3).

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Figure 3.

The factors made the subjects disapproval or partially disapproval of the recommendations.

We also analyzed the factors that led the subjects to consider the recommendations infeasible. The lack of working time (16.33%), the shortage of professional nurses (12.74%), the lack of training and education (10.59%), the lack of professional knowledge (9.22%), the attitude of patients toward nurses (8.28%), and the lack of capital (7.53%) were the factors contributing to the subjects’ perceived infeasibility of the recommendations in China (shown in Figure 4).

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Figure 4.

The factors made the subjects think the recommendations infeasible in China.

Group comparison

For more in-depth analysis, we further separated the subjects into two groups according to their age (232 subjects ⩽30 years old and 206 subjects >31 years old). We found a greater number of subjects in the older group expressed their approval and considered the recommendations more feasible (Figure 5(a) and Supplemental Figure S1).

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Figure 5.

The level of agreement with the EULAR recommendations by different groups of items: (a) age group; (b) educational background; (c) years of work experience; and (d) professional title.

We then allocated the subjects into two groups according to their educational background. There were 115 subjects with technical secondary school or junior college educational background and 323 subjects with a bachelor’s, master’s, or doctoral degree. There was no significant difference in the results of approval and feasibility analysis between the two groups (Figure 5(b) and Supplemental Figure S2).

In addition, the subjects were divided into three groups according to the years of work experience as a rheumatology nurse: <3 years (N = 166), 3–10 years (N = 166) and ⩾10 years (N = 106). As a result, the subjects’ attitude toward recommendations 2, 3, 4, and 7 was influenced by the years of work experience. Subjects with more working years considered these recommendations more favorable and practical than subjects with less experience (Figure 5(c) and Supplemental Figure S3).

Finally, we split the subjects into three groups according to their professional titles: nurse (N = 108), nurse practitioner (N = 213), and nurse-in-charge or professor of nursing (N = 107). More subjects with senior professional titles agreed with recommendations 2, 3, 4, 6, 7, and 10 than subjects in other groups (Figure 5(d) and Supplemental Figure S4).

Discussion

The role of nurses in the management of CIA differs greatly among countries and across regions due to factors including educational level, training, and expertise. Our study showed that the EULAR recommendations were widely accepted among Chinese rheumatology nurses. However, certain practicality issues may be restricting the nationwide implementation of the recommendations.

Our study indicated there was a certain degree of misunderstanding toward nurses’ roles among the patients, where the patients did not accept the extended roles of nurses. Moreover, H Jiang et al. revealed a discrepancy between the patient-perceived quality of nursing care and the perspectives of clinical professionals.^5,6 Therefore, patients should be given access to a wider range of information and knowledge about CIA management from nurses for better communication between the patients and nurses, ultimately improving the effectiveness of CIA management.

The EULAR recommendations propose that nurses should promote self-management skills and participate in comprehensive disease management in order to attain a greater sense of control, self-efficacy, and empowerment for the patients.^1,7,8 To achieve this, rheumatology nurses should master the skills and knowledge required for disease management, which are currently scarce among nurses according to our study. A system of our own is required for providing continuous education in order to maintain basic and advanced knowledge and skills, according to the EULAR recommendations.

Nowadays, the role of nurses and the needs from patients have both been expanding rapidly due to the new treatment regimens and changes in medical models. ⁹ Accordingly, the strengthening of nurses’ professional self-identity should be prioritized over professional knowledge. ¹⁰ It is essential to create a well-rounded training system to help nurses clarify their roles and tasks as well as conforms to role norms. However, to set the stage for this approach, a more complex restructuring of services will be required.

Overall, our study illustrated that the roles, tasks, and qualifications of nurses should be clearly described in future frameworks to enable new models of nursing that take into account the value of nurses in the management of CIA in China. A limitation of this study is that the doctors were not surveyed. Future studies should assess the perceived feasibility and level of agreement of the doctors with the EULAR recommendations. Nevertheless, the educational agenda of this study will help to expand the role of nurses based on national policies and will support the development of professional training and educational systems with the aim of providing better care for the patients, thereby bringing added value to the patients at a lower cost.

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